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l WELL I PUMP PERMIT SCANNED SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"'FL-STOCKTON CA 95202 - (209)463-3420 i NON-REFUNDABLE PERMIT CA L(209)9 -76 7 FOR I%SPECTIO%.i EXPIRES I YEAR FROM DATE ISSUED /qy/ U JOB ADDRESS L'-7 + / -r- , CITI'1ZIP ; �� �.r 7 CROSS STREETl,r. Ll,! !/,I�rt..J +y AP'N_ U r �C1 L 3 PARCEL SIIZZEE 4 Y[ i OWNER NAME G'`1 /T]+-11 7 PHONE t OWNER ADDRESS / 7I� CITYYSTATEIZIP CONTRACTOR 1- 'S1 eZ�r PHONE f/ / / 3 CONTRACTOR ADDRESS � ` P CITYISTATEIZJP / .(J SUBCONTRACTOR PHONE 1 SUBCONTRACTOR ADDRESS CITYISTATE12tP ! LICENSE ❑C-57 0 C-61 ❑D-09 ❑Other NUMBER EXPIRATION DAT£ F1 GEOGRAPHICAL INFORMATION; Coordinates X Y Township-�_ Range $cetion 3I[ IvTESDEDUSE 0 Domestjc!Privare �rrigatior,/Agricuttural ❑Industrial 0 Water Quality Monitoring C]Soil SamplinglCharaelerization � Q Public Water System Vdifferem from wriem arer ysrem,Mme omau:ame or one.vetoer TYPE OF WORK ❑New Well ❑Replacement Well )i1 Nell Alteration/Modification ❑Test Mole Q Other f b b umber of wells number of borings mer oarn: ' ❑M1lonitoring Weil(s) n Q Sail Boring(s) Q Geotechnical nu � Q Well Destruction n Out-Of-Service Well ❑Out-Of-Service Well Renewal D New Pum ❑Pump Re lacement 0 Pump Repair $Eross-Connection Repair WELL CONSTRUCTION Drilling Method 1:Mud Rotary 0 Air Rotary ❑Auger Q Cable Tool Q Push Point 13 Other Proposed Well Depth ft Excavation in diameter ©Open Bottom Q Gravel Pack!Gravel Size in diameter ❑Conductor Casing in diameter 1 Conductor Casing Depth ft Well Casing FDiameter_in Thickness/GaugerASTM Sched 11 Steel ❑Plastic Q Stainless Steel 11 Other Grout Seal Depth ft C1Neat Cement(94 1h hag/5-10 gai water) ❑Sand Cement .Yuck mi.r/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids—% Name ❑Specs on File Q Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall 0 Other ❑Retardant!Accelerator(name) PEDESTAL Installed By ❑Driller Q Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width R Length ft Thick in ❑Christy Bax ❑Stove Pipe PU%IP ❑Submersible ❑Turbine Q Other HP Pump Set It Standing Water Level tt WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ti Depth to Water fl ❑Casing to be Perforated from fl to It Sealing,Material 11 Near Cement(94 h5hag/5-10 gut wider) Q Sand Cement rack mix 17 gal water ❑Bentenite Pellets Fs ❑Bentonite(20%solids) ❑Manufacturer Spec°/solids o Name ❑Specs on File ❑Specs Submitted Placement Methed ❑Pumped ❑Free Fall ❑Other Q Complete with mushroom Cap R below grade 0 Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JO.AQUIN COUNTY ORDINANCES, ST E LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 1S CURRENT AND ACTIVE WITH THE,C IFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL 'WORKERS COMPE\�ATIO:N LAWS OU ADVANCE NOTICE REQUIRED FO SPECT ONS—PLEASE CALL(209)953-7697 SIGNED TITLE �• ... DATE �`.. F I L IL--- 4 I - ) A ZZ Yi Yr ` DE ARTMFNT USF.ON y y Application Accepted By � f~f� _gale G Area� Employee ED# �/ Grout Inspection By Date 11 SPECIAL Well Permit Pump Inspection By ( �� Date ❑ WAIVER Received Destruction inspection By Date Constructed Well Depth ft } COMMENTS — Q ri 1 PESC Received Check#1 Amount PermlU I Codes Info By ash Remitted Date Senice Rc uest# Invoice# WeHIDq 1 EHD 43-02-066 }CASTER WATER WELL PERMIY ' 12r6r2002